Parent/Guardian Form

We ask that you fill out this form once for each child involved in The Overflow. Your responses are kept confidential and will stay on file for all future programs and activities.

Parent/Guardian First Name*

Parent/Guardian Last Name*

Email of Parent/Guardian*

First and Last Name of Child*

Date of Birth for Child*

Month

Day

Year

Does the child have any allergies?*

Yes

Is the child taking any medication?*

Yes

If you answered yes to any of the questions above, please supply additional information.

Please provide the name and phone number of one additional emergency contact.*

I understand that participation in The Overflow NC Inc. programs involves outdoor and hands-on activities. I release and hold harmless The Overflow NC Inc., its staff, volunteers, and affiliates from any and all claims, demands, actions, or liabilities.*

Yes

I give permission for my child to be transported by The Overflow NC Inc. staff or volunteers for official program activities and events. I understand that all reasonable safety measures will be taken to ensure my child’s wellbeing during transportation.*

Yes

I give permission for The Overflow NC Inc. to photograph and/or record my child during program activities for use in promotional materials, social media, website, or other nonprofit communications.*

Yes

Initials*

I declare that the info I’ve provided is accurate and complete.

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Address: 3706 Piedmont Road

Morganton, NC 28655

Email: jared@myoverflow.org

Phone: 828-205-7867

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